Medication Errors

Just how bad is the problem?

It's bad: Errors cost nearly $200 billion a year

Adverse drug events in hospital patients lead to excess lengths of stay, extra expenditures, and mortality - costs totaled $8.4 million in one year alone for a 700-bed teaching hospital. Some medication errors are preventable, and you can take steps to avoid being blindsided. The most common causes are confusing packaging and labeling, similar drug names, illegible orders, misread abbreviations, and lack of adequate patient counseling.

Notwithstanding progress toward medication error prevention, statistics show the problem may be growing:

· A recent poll of 1,500 Americans by the National Patient Safety Foundation of the American Medical Association in Chicago revealed that 42% of participants said they or a close friend or relative had experienced a medical mistake. Of those, 28% attributed the error to physician carelessness, improper training, and poor communication. An executive summary of the survey is available at the Web site of the National Patient Safety Foundation, http://www. ama-assn.org/ med-sci/npsf/pressrel/execsum4.htm.

· A recent nine-year study revealed that pharmacists reported more than 11,000 hospital prescription errors. In 1987 there were 522 significant prescription errors at the Albany (NY) Medical Center, compared with 2,115 there in 1995.1

· The number of medical accidents occurring each year among hospital patients nationwide may be as high as 3 million and cost as much as $200 billion a year.

· From 1991 to August 1997, nearly 3,000 medication errors were voluntarily reported to the Rockville, MD-based U.S. Pharmacopeial Convention (USP).

· A study of injuries to patients treated in hospitals in New York State found that 3.7% experienced adverse events; 13.6% of them led to death and 2.6% to permanent disability. More than a quarter of those errors were due to negligence.

· A study of errors in one intensive care unit revealed an average of 1.7 errors per day per patient, of which 29% had the potential for serious or fatal injury.

· Errors account for up to a quarter of deaths from heart attack, stroke, and pneumonia.

· Medication errors accounted for the majority of the 200 sentinel events the Joint Commission on the Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, had reviewed under its accreditation watch program as of last fall. Of those, 33 deaths resulted.

In a recent article that attributed thousands of deaths to medical errors annually, The New York Times Magazine put it this way: "Three jumbo jets crashing every two days. If the airlines killed that many people annually, public outrage would close them overnight. Hospitals kill that many patients every year because of missed diagnoses, medication mishaps, and other preventable errors. Yet there's hardly a whimper of protest."2

USP - a venue for anonymous reporting

Studies show nurses underreport errors because they fear punitive actions. When errors are swept under the carpet, dangerous situations can continue unchecked.

"Punishment is not the way to get rid of errors - it gives incentive to hide errors," said Lucian L. Leape, MD, of the Harvard School of Public Health in Boston in a news conference sponsored by the National Patient Safety Foundation. Many hospitals react punitively if a practitioner makes an error, says Michael Cohen, president of the Institute for Safe Medication Practices (ISMP) in Warminster, PA. "And then you have state board hearings and even the criminal courts."

"The anonymous aspect of reporting is important," says Shawn C. Becker, BSN, RN, manager of program development at USP, the Rockville, MD-based private, nonprofit agency that accepts anonymous reports and monitors errors. "Names are not taken in reports," Becker says. "That's not what we're interested in." USP's database allows hospitals to benchmark against one another so future errors can be avoided.

"We get about 500 reports per year of medication errors," says Becker. "The information goes into a database, then is sent to the FDA and to drug manufacturers if there's a labeling or packaging error." The USP analyzes database information and does quality reviews. Case studies and suggestions on how improvements can be made in your system can be found at its Web site (http://www.usp.org). Also located there is the on-line nationwide Practitioners' Reporting Network that tracks, analyzes, and compares product problems nationwide. The network comprises four programs:

· The Drug Product Problem Reporting Program. All reports to this program become part of a database that monitors the quality of drugs in the marketplace.

· The USP-ISMP Medication Errors Reporting Program. This program makes possible the confidential, anonymous reporting of actual or potential errors.

· The USP-SNM Drug Product Problem Reporting Program for Radiopharmaceuticals.

· The USP-AVMA Veterinary Practitioners' Reporting Program. The last two programs provide ways for professionals to report adverse reactions, quality problems, and misadministrations.

"People don't always wait for an error to occur before reporting," Becker says. "We get a lot of reports on potential errors. We don't want to wait till something happens. We want to be able to tell people how do something about it early on."

The Joint Commission is aware of USP and its reporting program because they see its potential for an impact on public health, says Becker.

References

1. Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital: A 9-year experience. Arch Intern Med 1997; 157:1,509-1,620.

2. Weinstein MM. Checking medicine's vital signs. The New York Times Magazine 1998; April 19:36-37.

[Editor's note: To report a medication error incident, potential or actual, call (800) 4-USP PRN [(800) 487-7776]. Or mail or fax a "Medication Errors" or "Drug Product Problem" reporting form to USP-PRN, 12601 Twinbrook Parkway, Rockville, MD, 20852; fax (301) 816-8532. (See two USP reporting forms on pp. 105-106.) You can report on-line as well at http://www.usp.org/prn.]